Alpha House Registration Form

Nursery & Pre-K Programs

I am enrolling my child in:

Full Day Session 1

8:00am – 2:45pm (5 days per week) Must be 3 yrs. Old by September 1.

Full Day Session 2

8:00am – 2:45pm (5 days per week) Must be 4 yrs. Old by September 1.

Morning Session 1

8:00am –11:00am (5 days per week) Must be 4 yrs. Old by September 1.

Afternoon Session 1

11:45am –2:45pm (5 days per week) Must be 4 yrs. Old by September 1.

Morning Session 2

8:00am –11:00am (3 days per week) Must be 3 yrs. Old by September 1. Tue/Wed/Thurs

Afternoon Session 2

11:45am –2:45pm (3 days per week) Must be 3 yrs. Old by September 1. Tue/Wed/Thurs

Kindergarten Programs

I am enrolling my child in:

Full Day Session

7:45am – 2:30pm (5 days per week) Must be 5 yrs. Old by September 1.

After School Programs

I am enrolling my child in the after school program:

Yes

No

If yes, please complete the Kid’s Club registration form.

Background Information

Previous School:

Referred by:

Special services your child has received:

Allergies or other medical attention needed:

Student Information

Child's Name:

Sex:

Femaie

Male

Child's Date of Birth:

Telephone:

Email:

Address:

City/Town:

State/Province:

ZIP/Postal Code:

Background

Parent/Guardian Name 1:

Parent/Guardian Name 2:

Parents Marital Status:

Telephone

Parent/Guardian 1 Occupation:

Parent/Guardian 1 Work Contact:

Parent/Guardian 2 Occupation:

Parent/Guardian 2 Work Contact:

Emergency Contacts

You must list two emergency contacts below:

Name:

Relationship:

Telephone

Name:

Relationship:

Telephone

Alpha House Registration Form

Nursery & Pre-K Programs

Kindergarten Programs

After School Programs

Background Information

Student Information

Background

Emergency Contacts

A Journey of Support